Obama Administration Releases Draft Rules On Preexisting Conditions

Source: TPM

SAHIL KAPUR 12:24 PM EST, TUESDAY NOVEMBER 20, 2012

The Department of Health and Human Services released draft rules Tuesday regarding the implementation of a critical piece of the Affordable Care Act -- the ban on insurer practice of denying coverage to people with preexisting conditions. In an advisory, HHS described the rule, which is not yet final:

A proposed rule that, beginning in 2014, prohibits health insurance companies from discriminating against individuals because of a pre-existing or chronic condition. Under the rule, insurance companies would be allowed to vary premiums within limits, only based on age, tobacco use, family size, and geography. Health insurance companies would be prohibited from denying coverage to any American because of a pre-existing condition or from charging higher premiums to certain enrollees because of their current or past health problems, gender, occupation, and small employer size or industry. The rule would ensure that people for whom coverage would otherwise be unaffordable, and young adults, have access to a catastrophic coverage plan in the individual market.

HHS also issued draft regulations on the types of "essential health benefits" that insurance plans must include, alongside other insurance market reforms.

"The Affordable Care Act is building a health insurance market that works for consumers," said HHS Secretary Kathleen Sebelius. "Thanks to the health care law, no one will be discriminated against because of a pre-existing condition."

3. Where's the universal?

It doesn't insure everyone. No one is guaranteed access to health CARE. The cost of care is going up faster than peoples salaries and ability to afford health care. People already go bankrupt WITH health insurance.

10. Always had universal opportunity

If you could afford it. Still the same, merely more people who may be able to afford it. But not universal by any stretch. Leaves roughly 8% of the population, mostly those most needing help, uninsured and unable to afford health CARE. Even more that are insured but STILL can't afford health care.

ACA was "ground breaking" because it extensively federalized the health insurance industry and mandated that private citizens access medical care solely through insurance companies (unless on a government insurance program). Not exactly the kind of ground breaking many of us were hoping for. But if it truly had been universal health CARE, I might have accepted the compromise.

As it is, costs will still continue at unsustainable rates (according the the White House) and the political will to address it has been crushed for the better part of a decade or more.

14. No, you do not. The ACA will be the first time in American history that a law ensures that

any and all Americans can purchase some form of health insurance.

So while universal opportunity isn't here today, it will be in 2014. We don't really know how the public is going to react to having access. I believe people are going to flock to the new plans, but I'm an optimist.

Nothing is perfect, but how our system is evolving feels American. We're all on our way to a more perfect union.

49. They could always purchase "some form" of insurance

Of course much of it was way too expensive for most. And those with certain pre-existing conditions were just better off paying directly. The change is that now the feds are regulating the health insurance markets and they have traded pre-existing conditions on some for mandates on all and a requirement that one must deal with an insurance company in order to get health CARE. Oh, we will let you out of the mandate if your insurance costs too much but the government doesn't want to subsidize it. Of course you still won't have insurance, much less health CARE. Not sure how you translate that into "universal".

Getting back to the original post, my concern was that the "guarantee" was that people with pre-existing conditions could buy "catastrophic" insurance. It isn't clear if this is true. The article wasn't clear. But if it is so, that's pretty minimal insurance for people with true pre-existing conditions.

11. No one?

Well, I guess the millions of people who eke out a living just above official 'poverty level' but who don't have extra hundreds of dollars a month to buy insurance, let alone co-pays, are just 'no one'.

Boy it is fun being poor and invisible in America, especially when you are sick too!!

15. If you are that close to the poverty level, your coverage will be subsidized

Just because people are poor doesn't mean that they're clueless about what's going on. They want insurance. Growing up, if my family had access to this kind of coverage, it would have allayed many fears about losing everything if someone needed surgery.

22. That's not quite true

Analyses of the subsidies show that there are millions of people who will either make too much to qualify for the subsidy but will still be extremely hard-pressed to afford premiums *and* copays etc -or- who will qualify for subsidies but will still find the premiums and copays prohibitively expensive. This is a simple truth.

There is no 'universal' to this health care. The pre-existing conditions piece of this legislature is vital, but it by no means creates universal access to health care to all Americans.

I have not and will not imply that 'poor people' are 'clueless' about this or anything else. Please don't assign that classist agenda to me, thanks.

24. What are you talking about?

I wasn't replying to you, and I wasn't criticizing the pre-existing conditions rule. I was pointing out the fact that there is nothing 'universal' about this health care law (unless you are talking about the increased profits that insurance companies will likely, universally, recieve). The poster I was replying to said 'Universal opportunity - no one can be denied coverage' and that is patently untrue. People who cannot afford it will be denied coverage.

Which implies that low-income-but-not-impoverished people are 'no one'. I take offense to that.

52. Should that happen, and it very well might, we should NOT throw the baby out

with the bath water. We will apply a fix, and each fix for ACA problems will get us another step closer to Single Payer.

If you can't handle this, go live in Canada or Europe. Americans are going to have to wait for perfection - I may not live to see it, but I sure as hell will support policies that move us closer to it.

55. First of all

cool off with the condescension, thanks. I have no desire to move out of the country.

Second, as for 'we will apply a fix', I would love it if you are right, but historical evidence implies otherwise (also, I am confused as to whom 'we' is - I am not a member of the ruling political or financial classes...). One step forward, two steps back is more like it. See 'The New Deal' for an example. Oh wait, most of that progress is gone, it's pretty hard to see anymore. It has been chipped away, not strengthened and expanded. See also efforts at campaign finance reform, labor laws, corporate accountability, and many environmental regs as further examples. Crumbs are thrown, they are chipped away at until there is nothing left, and the cycle continues. Real conditions for real working people continue to decline steadily.

Next, I am not 'throwing the baby out with the bathwater'. I am simply pointing out that a previous poster's assertion that the ACA offers universal access to healthcare is flat out wrong.

Bottom Line: You seem to be implying that falsehoods should be ignored if the truth is unpleasant. I beg to differ. I think MLK was more concerned with speaking truth to power rather than hiding the bad things under the rug or making faith-based assertions that things will just get fixed if we stop complaining.

61. Excellent post. nt

13. You mistake this for health "care" reform. That's not what it was for.

Tens of millions of people cannot afford it, it does relatively little to restructure and regulate these bastards who have held profit above people for decades, and hands them billions of taxpayer dollars to run at multiples of overhead cost and lower quality when compared to government-provided care.

Look at how much money the "managed services" companies are investing into carving out new hunks of profit, and paying their CEO salaries, ranging from $20 million to 49 million -

They see the billions coming down the pike to them, and can't wait to grasp what will be a hell of a profit. And if anyone thinks they haven't got room to grow, that the weak restrictions one sees today will be barriers, watch the Junk Bond, aka Private Equity, activity picking up in this area. They are licking their chops, because your money, and your health, is going to be completely in their hands in a few years.

17. You have your view of the future and I have mine. The ACA is a platform that will enable us

to build upon and improve.

Like I said earlier. I'm an optimist and I trust the President and the Dept. of Health and Human services to make care more accessible for all Americans. It's one of the many reasons why I cast my vote for President Obama.

Do you think this is the end of the line for the HC law - one and done? It isn't carved in stone.

34. Yes

Do you think this is the end of the line for the HC law - one and done? It isn't carved in stone

Although there will be constant attempts to undermine it and reduce the costs, as well as the occasional attempt to modify small portions either way, this President and the current congress will not touch ACA for 4 years. And even if we get a Dem president next time, they won't go near the topic, much less any large congressional effort. The president won't expend any more legislative "capital" on this topic. His remaining efforts will be economic and entitlement reform. He won't try for major changes to the ACA. He won't close Gitmo. He won't prosecute torturers. He won't renegotiate NAFTA. He won't try to get rid of the mandate or accomplish the public option. He'll continue to "lock out" single payer. And he won't lift a finger to decriminalize marijuana.

40. "He won't close Gitmo"

41. Sorta

He campaigned on closing it the first time around (as did McCain), and he's given up. Truth is, he never intended to. We found out after the election, his definition of "closing" was to move it to Illinois.

36. I don't think it's the end of the line at all. Look at all the merger and aquisition activity

going on to increase profits and consolidate\strengthen power. They are working 24 hours a day, 7 days a week, to figure out the best way to manipulate this.

Trust all you want. We have been trusting for a long time. Now we have more people on poverty, more working poor, more on food stamps than we have had in freakin' decades, and holding out the promise of health care they can't pay for to a family that works full-time and still needs food stamps and reduce-priced lunches, while giving nothing but excuses for the lack of decent employment is worse than cruel.

4 years from now people will be even more subservient to insurance cos than ever before, and 3% overhead provided by government programs will be on the way to a fading memory.

And we will all be poorer for it, despite some eye-candy that people want to latch onto.

You are correct, we each see different things coming down the pike. But I don't think that light is the end of the tunnel. We will see when we are closer...when the insurance companies are richer, and the people poorer.

4. I don't understand

The rule would ensure that people for whom coverage would otherwise be unaffordable, and young adults, have access to a catastrophic coverage plan in the individual market.

HHS also issued draft regulations on the types of "essential health benefits" that insurance plans must include, alongside other insurance market reforms.

Catastrophic coverage? "Essential healt benefits"? Do these go together? I tend to think of catastrophic as limited benefits, mostly after one spends a fair amount of money first. Is this the whole "bronze, silver, gold" concept playing out?

12. Quite the opposite

Catastrophic plans are mostly applicable to people who can afford very high deductibles. Otherwise, they go bankrupt from the uncovered costs. Alternately, they can be most attractive to those who can least afford health insurance because they tend to have the lowest premiums.

48. Thank you :)

31. Yes, do you

Health insurance plans, especially catastrophic, often don't pay a dime until you pay thousands in deductibles. Then, even after that, they often only "split" the costs 70/30 or so until higher out of pocket limits are reached. These can be 10 or 15K. This can ruin many folks, especially those that also lose their income during these catastrophic periods. There are people with fairly "normal" plans right now that have gone bankrupt even while having insurance. And this is from things vastly less than catastrophic.

And mind you many of the drugs aren't included in the out of pocket limits so these can add thousands on top of the deductibles and out of pocket expenses. Large numbers of people, especially those with significant pre-existing conditions, don't necessarily have savings this large, much less mortgages they can leverage (or already have).

Catastrophic insurance is a lousy idea for someone who doesn't have the income to support the upfront costs. But they are attractive to someone who doesn't have the income for the premiums for more complete policies.

43. Yeah, what's $5k? Nothing. Even when you add on

$4 or $5k in co-pays, nothing! Anyone could afford that right? They must have extra money laying around, otherwise why would they get such poor coverage?

Maybe you should get out of your well off bubble and realize how some of us have to live.

I'm living it now. Lost my job two years ago, when my Cadillac plan COBRA went from $895 per month to $1100 per month I had to go to a state subsidized plan that cost me $640. Quite the savings huh? But my deductible went from $0 to $2400 per person, my co-pays doubled for most things and more than that for prescriptions. So now when I go to the doctor, Cardiologist because of my heart (quad-bypass and two stents) and my Urologist (bad prostate), not to mention my GP, I have to make payments for the office visits. When they want me to have tests done to measure my progress or more likely, lack of, I have to tell them I can't afford it. When they want to see me every 6 months, I have to tell them I can't afford it. But I'm lucky, in three years, if I live long enough, I will be able to get Medicare. We are lucky my wife hasn't had to go to the doctor more than twice in the last two years.

This is exactly what is going to happen with the ACA and the high deductible policies, I'm just a preview. Remember too, I'm under a New York State subsidized plan now. I've also had all of my prescriptions changed to lower cost ones, doctors aren't too happy about not being able to monitor the affect, but then again I can't afford those tests either. I'm slowly going in the hole.

Do I understand how insurance works? Yes I do, insurance spread the burden equally among many people. That way the ones that need it the most pay no more than the ones that need it the least, the burden is shared. What is proposed is no such thing. When companies can charge people with pre-existing conditions more that is not sharing the burden equally.

Hopefully the ACA is just a good start, although not as good for some as for others. I certainly hope so. Time will tell.

38. Lucky for your dad

that he wasn't addicted. That's not the case for the majority of smokers. But you're right that smoking is a choice but it's also an addiction. This choice/addiction does result in increased medical costs.

My issue is that once you include a choice or addiction in the formula for insurance premiums, then you also open the door to other choices or addictions when the political climate is right and the public has been conditioned to accept it.

Eating the wrong foods and overeating or an addiction to sugar leads to obesity which also results in increased medical costs. The public is already being prepared for this being used as a reason to charge higher premiums.

Drinking alcohol can also become an addiction and result in increased medical costs and is a choice.

Living in a high crime area is a choice and can lead to increased medical costs for people who live in those areas.

Working long hours and subjecting yourself to high stress is a choice and can lead to increased medical costs.

Allowing smoking to be a factor in determining higher health insurance premiums is a slippery slope that insurance companies will cultivate.

46. I was addicted to smoking

More than two decades. And, yes, I was VERY addicted -- first thing I did in the morning and last thing I did at night. Anyone can quit.

Your analogies fail because there is not a direct and objective link established for ANY of the things that you mentioned. High sugar and fatty foods and alcohol can all be consumed within safe limits. You enter danger zones when consumption interacts with genetic predispositions. Someone with a family history of diabetes may be able to eat far fewer carbs than someone who comes from a family with naturally high metabolisms.

There is NO SAFE limit for smoking or genetic predisposing condition for smoking. They are not the same.

Also, as far as stress and high crime area, that data varies among individuals and has not been quantified. You would have no way of objectively setting rates.

It's a slippery slope when you start making false analogies to justify or excuse smoking. There is a scientifically proven cause and effect between smoking and increased health care costs, even something as simple as getting more upper respiratory infections.

I hope the ACA covers costs and assists people with stopping smoking, but I have no issue with smokers being charged more. I also hope there is more federal emphasis on combating obesity and increasing fitness. But after this week's Twinkie debacle, I doubt that stands a chance.

33. Not so nefarious

Medical costs are generally higher in metropolitan areas so insurance rates are generally set along zip codes to take the cost-of-care into account. It is how rates are currently set and it makes sense.

35. Hope You Are Right

32. This is excellent

This rule would put everybody on an even footing. It hits close to home for me. My son was denied insurance because he had the audacity to have a brain tumor (benign) when he was 16. It was removed and he has been fine since and has no medical issues aside from a congenital partial hearing loss in one ear. He applied for a standard, individual policy and the insurance company basically laughed at him.

He was obtain to obtain insurance through a state run high-risk pool but the insurance is considerably more expensive with lesser benefits. But at least he has something.

In another year he will go into the pool along with everybody else who needs individual insurance. This is how it should have been all along. If he was working in a company with a group policy, there would have not been a problem but because he is self-employed, he has been discriminated against.

39. K & R

44. For profit insurance will never "work for consumers"

It is not meant to. It is meant to make a profit, and that's what it "works" for. Period.

And I took a look at the proposed rates deemed "affordable" and the subsidy levels when this monstrosity first emerged - affordable? Har de har har. However, the Insurance Vampires are licking their teeth in anticipation.

45. Oh, and btw, "consumer" is a misnomer when applied to health care

To be a "consumer" of something you have to buy implies that you have choice, discretion, options. We are rarely "consumers" of health care - we are patients in need of health care. We can't "choose the coverage that's right for us" because we DON'T KNOW WHAT WE'LL NEED TOMORROW.

Talking about health care as a "right" in the same breath as talking about it as a "consumer" commodity is crazy talk.

But then, that's the function of a devolved "Liberalism" - to talk crazy with a straight face.